The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Williams SC, Schmaltz SP, Castro GM, et al. Jt Comm J Qual Patient Saf. 2018;44:643-650.
The Joint Commission identifies inpatient suicide as a sentinel event. Little is known about the epidemiology of hospital suicides other than that they are rare and occur mostly in psychiatry wards. Researchers examined two national databases to develop the first data-driven appraisal of hospital suicide rates. Nationally, between 49 and 65 hospital suicides occur each year. Nearly 75% happen during psychiatric treatment, and the most common means of death is hanging. This hospital suicide rate is an order of magnitude lower than prior estimates. An accompanying editorial raises concerns about the much larger epidemic of suicide immediately after psychiatric hospital discharge. A prior WebM&M commentary highlighted additional strategies to reduce hospital suicide risk.
Howard IL, Bowen JM, Shaikh LAHA, et al. Emerg Med J. 2017;34:391-397.
Trigger tools can identify patient results that may represent adverse events in an automated manner. This study determined potential triggers for adverse events in the emergency department setting. The final 8-item trigger tool identified through an iterative validation process had a sensitivity close to 80% and specificity around 60%, in line with trigger tools in other settings.
… of teamwork, team training, and patient safety. … David P. Baker, PhD … Executive Vice President Center for Research, … We spoke with her about new thinking about teamwork. … Dr. Robert M. Wachter … : What got you interested in teamwork? … …
This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.
Professionalism in medicine is considered an essential component of safety culture, but efforts to monitor and address disruptive behaviors among physicians have not produced the desired outcomes. This commentary discusses the need for more explicit emphasis on building physician skills and attitudes to support zero harm, process improvement, high reliability, and commitment to excellence in all areas of medical care.
McCarthy D, Waite KR, Curtis LM, et al. Med Care. 2012;50:277-82.
Limited health literacy has been linked to poor comprehension of written instructions. This study found that spoken instructions were also frequently misunderstood by patients with poor health literacy.
Baker DP, Amodeo AM, Krokos KJ, et al. Qual Saf Health Care. 2010;19:e49.
This study describes the development and validation of the TeamSTEPPS Teamwork Attitudes Questionnaire, a survey instrument designed to measure attitudes toward teamwork in health care delivery. The TeamSTEPPS teamwork training program was developed as a collaboration between the Agency for Healthcare Research and Quality and the Department of Defense.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25.
Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.
Introduction of an electronic discharge summary was associated with more timely communication with outpatient physicians and improved communication of potential patient safety problems, such as test results that were pending at the time of discharge.
Baker DW, Wolf MS, Feinglass J, et al. Arch Intern Med. 2007;167:1503-9.
This prospective cohort study found increased mortality among elderly persons with poor health literacy, even after adjusting for confounding factors. Poor health literacy has previously been linked to inability to understand prescription drug labels.
Kripalani S, LeFevre F, Phillips CO, et al. JAMA. 2007;297:831-841.
Patients discharged from the hospital experience an unacceptably high rate of medical errors. Prior research suggests that suboptimal communication between hospital physicians and outpatient physicians could contribute to these problems. This study systematically reviewed the literature to determine the frequency of communication problems between physicians at hospital discharge and to identify interventions that ameliorated this problem. The investigators found that direct communication occurred rarely, and the primary means of communication (the dictated discharge summary) generally was not available in a timely fashion and often contained inadequate information for proper follow-up care. Based on this review, the authors provide suggestions for standardizing information transfer at discharge and improving the timeliness of communication.
Alonso A, Baker DP, Holtzman A, et al. Human Resource Management Review. 2006;16.
This article describes the development of the US Department of Defense's team training program for military health facilities, entitled TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). The program was based on two prior military crew resource management (CRM) programs and prior evidence in the field and was adapted to address issues encountered in military facilities, including the rapid turnover of personnel and the need to adapt to the cultures of specific military services. The program consists of teaching core skills in leadership, situation monitoring, team support, and communication through an interactive curriculum stressing application to everyday scenarios. The article extensively reviews the challenges of implementing the program and future plans for disseminating and evaluating the training.
Davis TC, Wolf MS, Bass PF, et al. J Gen Intern Med. 2006;21:847-51.
This study addresses the relationship between low health literacy and comprehension of common prescription drug warning labels. Patients at an urban primary care clinic underwent structured interviews to address their understanding of specific one-step warnings (ie, take with food) and multi-step warnings (ie, avoid prolonged exposure to sunlight while taking this medication). The majority of the study population had low or marginal health literacy, defined as reading at an 8th grade level or lower. Patients with low literacy were significantly less likely to correctly interpret warning labels, and multi-step instructions were misinterpreted by the majority of respondents across all literacy levels. Misinterpretation of these common warnings could conceivably lead to misuse of medications or adverse drug events.
Pronovost P, Holzmueller CG, Needham DM, et al. Crit Care Med. 2006;34:1988-95.
This study provides an evaluative framework for addressing whether our health care system is safer compared to years past. The authors discuss a measurement approach that focuses on the following: how often do we harm patients, how often do patients receive the appropriate interventions, how do we know we learned from defects, and how well have we created a culture of safety. Building on a model of structure, process, and outcome measures used to evaluate health care quality, the authors present a detailed discussion of attributes necessary for safety-specific measures. They provide a case-type example of their suggested process to illustrate their framework. Reflecting on the 5 years since release of the IOM report, past commentaries by Leape and Berwick as well as Wachter focused on progress in patient safety and provide further context to the efforts of this study.
Yap C, Dunham D, Thompson JA, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;31.
The investigators analyzed electronic records and found that dosing errors were common in ambulatory care settings for patients with renal insufficiency. They conclude that computerized decision support systems should be implemented in ambulatory care.
Paine LA, Baker DR, Rosenstein BJ, et al. Jt Comm J Qual Saf. 2004;30:543-50.
Johns Hopkins has been recognized for their efforts toward transparency, innovation, and successful engagement of their leadership, and this article provides a thoughtful model for other academic medical centers to mirror the rapid improvements made at Johns Hopkins.
Lindquist LA, Jain N, Tam K, et al. J Gen Intern Med. 2011;26:474-9.
Elderly patients often rely on caregivers—either family members or paid workers—to assist with important medical tasks such as taking medications and accompanying patients to appointments. This study found that more than one third of paid caregivers had inadequate health literacy, and a similar proportion had impaired numeracy (difficulty applying arithmetic operations to common tasks). As low health literacy has been linked to misunderstanding medication instructions, these findings imply that paid caregivers may themselves be a source of patient errors in the ambulatory setting.